Mike Pykosz

Let's get ahead of the issue of health insurers doubling as venture capitalists. In addition to describing how it creates risks for patients and clinicians, I outline recommendations for how to bring greater accountability and transparency to this practice. Thank you, Wendell Potter, for the opportunity to contribute to Healthcare Uncovered. #healthinsurance #venturecapital #healthcareinnovation #clinicians

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What does the future hold for retail medicine and virtual care? Walmart is the latest to announce their health center closure. https://lnkd.in/geZpMTkS. This following Optum news, VillageMD closing in Nevada, Teladoc Health problems, etc. What comes next? This is another in a long line of examples that technology and even consumer willingness are not enough when the reimbursement environment does not support particular care models. Are we getting ready to lose all the lessons painfully learned during the pandemic? Or will new virtual care models emerge following this round of closures?

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This 👂 podcast episode and insight’s from a16z Bio + Health's Julie Yoo spoke so clearly to the fundamental challenge facing both 🩺 clinicians and 🏥 healthcare systems.  There is a huge disconnect between supply, in the availability of clinicians, and demand, in the increasing volume and complexity of healthcare needs. -     36% of physicians plan to reduce their hours next year according to the AMA -     48% of physicians reported feeling burned out in a 2024 Medscape survey At the same time, the demographic baby boomer bubble and steady increase in the prevalence of major chronic disease, which consumes up to 90% of healthcare expenditures according to some estimates, is driving demand. With this context, Yoo points to a major opportunity for AI adoption in healthcare in 2025. Yeah, a VC hyping a wave of new AI companies that will replace the decades of training and experience of clinicians, the skeptic would say.  But Yoo is thoughtful in pointing to the role AI can play, and is already playing, through solutions such as ambient, autonomous scribe solutions (of which local star Abridge is leading the pack) in not replacing, but freeing up productivity for clinicians. There is so much unstructured context in both the complexity of disease and treatment options and the social/emotional considerations that we shouldn't be looking for AI to *replace* clinicians. But companies are getting better at finding the structured, repetitive and time-consuming places where AI tools can *help* clinicians. Nearly two-thirds of doctors cited bureaucratic tasks as the leading contributor to burnout. Rigorously trained-AI driven solutions can be a force multiplier for clinicians, and I’ve seen several interviews where nurses and doctors go as far as to say some of these solutions are ”restoring their joy in practicing medicine”. Our health is precious; and we rightly want any technology engaging with it to be developed thoughtfully and thoroughly tested. This requires top AI talent and diverse and realistic training data. Pittsburgh’s strengths in both areas is why we are an emerging hub for data-driven healthcare. #AIinhealthcare #clinicianburnout #healthinnovation #digitalhealth

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🎥 Exciting update: I recently joined Jody Tropeano Greene to discuss the DiMe Seal, a milestone in building trust and accountability in digital health. Check out our conversation here: https://lnkd.in/epMHYU5x 🌟 Launched at HLTH 2024, the DiMe Seal recognizes high-quality, trustworthy digital health software products. Since its debut, we’ve seen incredible momentum: 🏥 Healthcare systems and payers across the US are looking to the DiMe Seal to help de-risk their digital health software purchases 🌍 Digital health software developers across the world are recognizing the value of the DiMe Seal to distinguish their products in a crowded market 👉 Are you a developer of digital health software products? Pursue the DiMe Seal and join the leaders setting the standard for quality and trust in healthcare innovation. Register today and use the code HLTH25 for a 25% discount https://lnkd.in/eTb6rRbj Let’s continue to raise the bar for digital health together! 🚀 #DigitalHealth #DiMeSeal #HLTH2024 #Innovation #TrustInHealth

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Another large funding round in the virtual behavioral health space. It's interesting to note Talkiatry's focus on a physician-centric care model with W-2 providers, as opposed to most of the other players who are delivering care with 1099 mid-level therapists. However, it's still not clear to me how they are measuring care quality and outcomes, which is the foundation of true value-based care.

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"Hopes to rein in private equity investment in healthcare died in California last weekend." Patient care is more than a process; it is a profound human connection built on trust. Dr. Zirui Song, a healthcare policy professor at Harvard University and a general practitioner at Massachusetts General Hospital, highlights this essential aspect of healthcare. #PatientCare #HealthcarePolicy #HumanConnection #PrivateEquity

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Strong partnerships are essential to tackling these foundational levers effectively. By aligning goals and working collaboratively (with trust), we can create sustainable strategies (and comp models) that not only lift the tide but also empower everyone to succeed together. Bringing all back to the partnership!

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BCBS Minnesota and Herself Health have shifted from the FFS (Fee For Service) model to VBCs (Value-based Contracts). It would help increase payment incentives for quality while lowering the emphasis on quantity or transactional care with the ultimate goal of improving healthcare outcomes that commonly impact older women, such as osteoporosis, autoimmune diseases, and Alzheimer's. It will be interesting to evaluate how this model impacts the healthcare outcomes viz a viz expenditure for patients of Herself Health. Should more payers and ACOs follow suit?

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Although care consolidation is great for the companies doing the consolidating, the rest of us aren't faring as well. We have plenty of data showing that the acquisition of independent medical practices by PE firms results in higher revenue. Sadly, the care provided to the patients often gets worse. Most clinicians don't like working in an environment that prioritizes profits over patient care, so they often leave - abruptly or slowly by disengaging. Care consolidation also allows insurers to exclude those of us in private practice from contracts or offer us reimbursement terms that are significantly lower than they offer the consolidated groups.) Again, good for them - bad for people obtaining the care. In response to consolidation by PE and large health systems, insurers have begun buying up practices - creating this new payvider model (where the provider and payor are essentially the same entity). Although this model does nothing to solve problems for patients or doctors (or improve the actual quality of the care), it does keep them from being left out of the game of profiting from the delivery of care. I suppose it was only a matter of time before these two entities decided to work together! Personally, I can't see a lot of benefit coming out of this proposed partnership for anyone except for CVS/Aetna and the PE firm willing to play in the sandbox with them. It certainly isn't going to help those of us engaging in the healthcare system - as patients and providers. I have been living and breathing inside our healthcare system my entire adult life - as a patient, a physician, and an owner of a private practice medical clinic - and I still don't fully understand the system! I don't think this is accidental - and I'm certainly not the only one who is confused. The more I talk to my physician colleagues, the more I realize that we have to do something. We have collectively stayed focused on the practice of medicine while ignoring the business/economics/logistics of deploying medical care. In a way, we have essentially allowed this to happen. In our defense, most of us went into medicine because we wanted to be involved in patient care. Most of us chose this path very early on in our careers and have dedicated a significant portion of our lives to this field. We have sacrificed countless gatherings and holidays with our friends and families to take care of patients. We miss tucking our kids into bed at night more often than we like to admit. Asking us to dive deep into the economics and incentives in healthcare - and fix it - is a lot. However, it has to be done. What is the solution? https://lnkd.in/g8smuE88

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Elevance Health is creating a new #primarycare model that nudges their members to their owned clinics - essentially paying themselves ♻️ They’re partnering with a #privatequity firm, Clayton Dubilier & Rice (CDR), to create a #jointventure called Mosaic Health. What do we know: 🖼️ Mosaic is comprised of two of CDR’s portfolio companies, apree health (a digital navigation and clinical advocacy company formed when Vera Whole Health and Castlight Health merged) and Millennium Physician Group (a primary care platform serving 900 providers). 🧑‍⚕️ Elevance is following similar moves like their rivals, such as UnitedHealthcare, CVS Health, and Humana, all of which invested heavily in building out their #providernetworks, including through #acquisitions. 📈 Owning care sites will give these #payors more visibility into their members’ current and potential health conditions. This also diversify their revenue streams from their core businesses. 🧑‍🧑‍🧒‍🧒 They expect to treat 1M members across 19 states. Thoughts about #insurancecompanies being more involved in your health??

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#PublicHealth experts have stressed the urgency of driving awareness about the deadly impacts of rising temperatures across the globe. Proud to see how CVS Health is answering that call. 👇 In a first-of-its-kind initiative, CVS Health announced an environmental health impact program to help people most vulnerable to extreme weather events — like #HeatWaves — that can worsen existing chronic conditions. Initially available to our Aetna members with a goal to expand, this initiative will use advanced environmental data analytics and enable our care managers to contact vulnerable patients with tailored recommendations. Heat-related illnesses are preventable with outreach and intervention. Our initiative aims to provide up to a seven days' warning in advance of an extreme weather event, giving our members critical time to prepare. Read more about our initiative: https://cvs.co/3WWQFgl #TeamCVS

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Which founders fit the mold for success in healthcare? I spoke with Anne DeGheest, Founder and Managing Director at HealthTech Capital, about the key characteristics of successful #healthtech entrepreneurs. Listen to the full conversation here: https://lnkd.in/eqwUCkPx

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Well done Sanford! As RX costs continue to spiral out of control for many MCOs we should see an increased focused in utilizing biosimilars in pharmacy strategies as they can significantly impact costs by driving down overall drug expenditures. Here's how: 1. Cost Savings: Biosimilars are typically less expensive than their biologic reference products, sometimes by 15-30%, offering substantial savings on high-cost biologics used to treat chronic conditions like cancer, autoimmune diseases, and diabetes. 2. Increased Competition: The introduction of biosimilars into the market creates competition, which can push down the price of the reference biologics and other similar therapies. 3. Improved Access: Lower costs from biosimilars can improve patient access to biologic therapies, leading to better adherence to treatment plans and potentially better outcomes. 4. Formulary Design and Rebates: Managed care organizations can strategically include biosimilars in their formularies to encourage their use. Additionally, they can leverage rebates and negotiations with manufacturers for even greater cost control. 5. Long-Term Budget Impact: The adoption of biosimilars can contribute to a more sustainable healthcare budget by mitigating the financial pressure of covering high-cost biologics, which are often a major driver of healthcare costs. Overall, integrating biosimilars can play a crucial role in reducing drug spending, which helps managed care organizations manage costs more effectively while maintaining or improving patient care.

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This is quite incredible to see. Very few #CMMI demonstrations can point to any savings at all. And “…MSSP savings go further than savings generated by Medicare Advantage…” #ACO #VBP #Primarycare #MSSP #healthcareinnovation

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Check out the takeaways from the 2024 HMA annual conference! As we plan for the 2025 event, we want to know what topics are rising to the top for you? Who do you want to hear from? Message me with your ideas!

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Oshi Health: Insights to Scale a Specialty Care Model… It is hard to stomach the fact that there are an estimated 60 – 70 million Americans who suffer from gastrointestinal (“GI”) conditions, costing the U.S. healthcare system approximately $140 billion annually, according to the National Institute of Diabetes and Digestive and Kidney Diseases. BCC Research tallied the costs of just the therapeutics and associated diagnostic procedures were $86 billion last year, increasing to more than $123 billion by 2028. There are now more than 100 million GI ambulatory care visits each year and GI conditions are thought to be one of the four most expensive diseases.   In part as a function of the pandemic when the healthcare system had to become virtual/on-demand/predictive/always-on overnight, there was a dramatic influx of capital in 2021 of nearly $30 billion invested in healthcare technology companies, much of which went to launch virtual specialty care models across many diseases.    As we now appear to be in an “emerging winners” phase of the market, some observations on what it takes to scale virtual specialty care models into substantial businesses. https://lnkd.in/eTJeAFBu Flare Capital Partners #digitalhealth

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